A recent blogpost by Administrator Seema Verma of the Centers for Medicare & Medicaid Services (CMS) announces CMS’s plan to “combine and standardize” the eight Compare websites into a Medicare Compare website.[1] At the same time, an unidentified spokeswoman wrote to McKnight’s Long-Term Care News, an on-line trade publication, that “‘CMS is interested in evaluating how resident or patient satisfaction scores could be added to the Nursing Home Compare website and Five Star Quality Rating System.’”[2] CMS’s two positions – promoting consistency among Compare websites and interest in satisfaction surveys for nursing homes – are in conflict. CMS’s websites for various health care provider categories report information on “patient experience,” as measured by federally-developed Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys; CMS does not report provider-developed “satisfaction surveys” on any of its Compare websites.
Consumer Assessment of Healthcare Providers and Systems
The federal Agency for Healthcare Research and Quality (AHRQ) “funds, oversees, and works closely with a consortium of research organizations to conduct research on patient experience and develop surveys that ask consumers and patients to report on and evaluate their experiences with health plans, providers, and health care facilities.”[3] CMS develops, implements and administers several patient experience surveys that are either developed by AHRQ or follow CAHPS principles.[4]
CMS distinguishes patient experience surveys from customer satisfaction surveys:
Experience is not the same as satisfaction
Patient experience surveys sometimes are mistaken for customer satisfaction surveys. Patient experience surveys focus on how patients experienced or perceived key aspects of their care, not how satisfied they were with their care. Patient experience surveys focus on asking patients whether or how often they experienced critical aspects of health care, including communication with their doctors, understanding their medication instructions, and the coordination of their healthcare needs. They do not focus on amenities.[5]
Examples of CAHPS Surveys Currently In Use
Hospital Compare includes tags with information on the following topics: General information; Survey of patients’ experiences; Timely & effective care; Complications & deaths; Unplanned hospital visits; Psychiatric unit services; Payment & value of care.
The tab for Survey of patients’ experiences reports the hospital’s overall rating on a five-point scale and then the hospital’s rating on each of 10 questions (with comparisons to state and national averages), including how often nurses communicated well with patients, how often staff explained medicines before giving them to patients, how often patients’ rooms and bathrooms were kept clean; and how well patients understood the type of care they would need after they left the hospital. The survey is given to a random sample of recently discharged hospital patients.
Home Health Compare includes tags with information on the following topics: General information; Quality of patient care; and Patient survey results. The Patient survey has 34 items, which are consolidated and publicly reported in five categories.
CAHPS for Nursing Home Residents
As for other health care provider categories, AHRQ developed the surveys. There are nursing home CAHPS surveys for three categories of respondents: long-stay residents, discharged residents, and family members.[6] AHRQ began its development of surveys of nursing home residents with focus groups, followed by cognitive testing of survey questions, and then field testing in the summer 2005 at 13 nursing facilities.[7] The resident survey includes a total of 45 questions: 17 questions, ranked on a 1-10 scale and addressing such issues as how much the resident enjoys mealtimes, how comfortable the temperature is; 17 yes/no/sometimes questions addressing such issues as whether staff helps with dressing, showers, and bathing; choosing bedtime; choosing clothes; 4 questions, ranked as often/sometimes/rarely/never addressing feelings of worry and happiness; and 7 additional questions about gender, education.[8] Unlike other CAHPS surveys, the CAHPS survey for long-stay residents is administered in person.[9]
McKnight’s Long-Term Care News reports that the CAHPS nursing home surveys were tested in 2006 and 2007, but that nursing homes rejected them.[10] CMS’s website listing CAHPS surveys now in use does not include any of the three nursing home surveys.[11]
Satisfaction Surveys
Advocates for residents strongly support soliciting, hearing, and acting on residents’ voices and concerns. Nevertheless, we oppose posting “satisfaction surveys” as they are currently developed and used by the nursing home industry.
AHCA’s Satisfaction Surveys
McKnight’s reports that several years ago, the American Health Care Association’s (AHCA) developed the CoreQ program (“Getting to the core of customer satisfaction in skilled nursing and assisted living”) for nursing homes and assisted living, with three questions for long-stay residents/family members and four questions for short-stay residents of nursing facilities. AHCA said the program was “independently tested as ‘a valid and reliable’ measure of customer satisfaction.”
CoreQ, coreq.org/.
The questions are answered on a five-point Likert Scale (poor (1), average (2), good (3), very good (4), and excellent (5)). Generally, surveys use an odd number of choices to allow for two positive choices, two negative choices, and one neutral option. CoreQ has three positive choices, one negative choice, and one, arguably, neutral choice. The three CoreQ surveys and their questions are:
SNCC (Skilled Nursing Care Centers) Long-Stay Residents
- In recommending this facility to your friends and family, how would you rate it overall?
- Overall, how would you rate the staff?
- How would you rate the care you receive?
SNCC Long-Stay Family
- In recommending this facility to your friends and family, how would you rate it overall?
- Overall, how would you rate the staff?
- How would you rate the care your family member receives?
SNCC Short-Stay Discharge
- In recommending this facility to your friends and family, how would you rate it overall?
- Overall, how would you rate the staff?
- How would you rate the care you receive?
- How would you rate how well your discharge needs were met?
Concerns about Satisfaction Surveys
McKnight’s reports that the nursing home industry has “heightened calls recently for publicly reported patient-satisfaction scores . . . in response to some of the administration’s more objectionable efforts to increase ‘transparency for consumers” – i.e., the abuse icon that CMS posts on a nursing facility’s homepage on Nursing Home Compare when the facility is cited with abuse at either an actual harm level (G-I) in the prior year or a potential for harm level (D-F) in two surveys in two years.[12]
The CMS spokeswoman identified “substantial challenges” to posting resident satisfaction scores for nursing home residents, “‘including funding, the data collection process, and regulatory construct.’”[13] Additional challenges identified in the article include “how to factor residents with dementia into the information” (with 47.8% of nursing home having a diagnosis of dementia,[14] accurately capturing their satisfaction is essential), “face-to-face data collection” (which is expensive and not used in other settings), and research finding that “proxies do not fill out forms the same as the actual person targeted.”[15]
Added to the concerns expressed by the CMS spokeswoman and those identified in the article are concerns raised by residents’ advocates:
- Facilities’ marketing offices often developed, and even today continue to use, satisfaction surveys to help promote facilities to new customers. One of the vendors that AHCA identifies as using its questions for satisfaction surveys describes its role: “BlueSky Creative, Inc. provides custom, full service marketing services for seamless rollouts within pre-set budgets and timelines . . . .”[16]
- CMS’s website should post only valid, publicly-developed information, not whatever satisfaction survey a facility wants to use.
- There are many additional reasons to question the validity of the results of satisfaction surveys:
- Residents may not want to complain about staff. Residents frequently say that staff do the best they can, but there are just not enough of them.
- Residents who know they cannot go home and feel they have no choice about living in a nursing home may try to “make do” and say the situation is better than they actually believe.
- Residents may be fearful of retaliation or just reluctant to speak about their concerns with a stranger who comes in to a facility and asks questions.
An Alternative Approach
Using the nursing home CAPHS surveys is the best option, since, like all other CAHPS surveys reported on Compare websites, it was tested and validated. However, if the CAHPS survey for nursing home residents is too expensive and too complex to administer, the Center proposes an alternative method for soliciting and reporting residents’ experiences – the federal survey process.
The federal survey process already includes surveyor interviews with residents[17] and residents’ councils[18] about a variety of quality of care and quality of life concerns. The existing survey process could be expanded and its results, separately and publicly reported on Nursing Home Compare.
Conclusion
The voices of residents and their families are important and should be heard. However, these voices must be true and meaningful. Instead of authorizing a new facility-controlled process, CMS should consider using CAHPS for nursing home residents or expanding the current survey protocol.
February 13, 2020 – T. Edelman
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[1] Seema Verma, “Making it Easier to Compare Providers and Care Settings on Medicare.gov” (Blog post, Jan. 23, 2020), https://www.cms.gov/blog/making-it-easier-compare-providers-and-care-settings-medicaregov.
[2] James M. Berklan, “CMS ‘interested’ in patient satisfaction scores for nursing homes,” McKnight’s Long-Term Care News (Jan. 22, 2020), https://www.mcknights.com/news/cms-interested-in-patient-satisfaction-scores-for-nursing-homes/.
[3] https://www.ahrq.gov/cahps/about-cahps/index.html.
[4] https://www.ahrq.gov/cahps/about-cahps/index.html.
[5] https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/CAHPS/index.
[6] https://www.ahrq.gov/cahps/surveys-guidance/nh/index.html.
[7] https://www.ahrq.gov/cahps/surveys-guidance/nh/resident/Development-Resident-Surveys.html.
[8] https://www.ahrq.gov/cahps/surveys-guidance/nh/index.html; click on Download the Long-Stay Resident Survey.
[9] https://www.ahrq.gov/cahps/surveys-guidance/nh/index.html.
[10] James M. Berklan, “CMS ‘interested’ in patient satisfaction scores for nursing homes,” McKnight’s Long-Term Care News (Jan. 22, 2020), https://www.mcknights.com/news/cms-interested-in-patient-satisfaction-scores-for-nursing-homes/.
[11] https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/CAHPS/index.
[12] CMS, “Consumer Alerts added to the Nursing Home Compare website and the Five Star Quality Rating System, QSO-20-01-NH (Oct. 7, 2019), https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/QSO-20-01-NH.pdf.
[13] James M. Berklan, “CMS ‘interested’ in patient satisfaction scores for nursing homes,” McKnight’s Long-Term Care News (Jan. 22, 2020), https://www.mcknights.com/news/cms-interested-in-patient-satisfaction-scores-for-nursing-homes/.
[14] Centers for Disease Control and Prevention, National Center for Health Statistics, Long-Term Care Providers and Services Users in the United States, 2015-2016, Appendix III. Detailed Tables, table VIII, https://www.cdc.gov/nchs/data/series/sr_03/sr03_43-508.pdf.
[15] James M. Berklan, “CMS ‘interested’ in patient satisfaction scores for nursing homes,” McKnight’s Long-Term Care News (Jan. 22, 2020), https://www.mcknights.com/news/cms-interested-in-patient-satisfaction-scores-for-nursing-homes/.
[16] http://www.blueskyci.com/; listed on Coreq, coreq.org .
[17] https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Nursing-Homes, click on New Long-term Care Survey Process – Slide Deck and Speaker Notes (slide 44, Resident Interviews, says: “Screen every resident; Suggested questions—but not a specific surveyor script; Must cover all care areas; Includes Rights, QOL, QOC; Investigate further or no issue).
[18] Long Term Care Survey Process (LTCSP) Procedure Guide (effective Nov. 25, 2019), https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/LTCSP-Procedure-Guide.pdf p. 46 (resident council meeting).